Male sexual dysfunction includes the following: decreased Libido, Erectile dysfunction (ED), ejaculatory disorders and disorders of orgasm. All types of sexual dysfunction increase with age.
Libido is the medical term for sexual drive or the desire for sex and decreased libido can occur in 5-15% of adult males. Libido is influenced by biological, psychological and social factors. Sex hormonal levels, stress and depression, endocrine conditions such as hypothyroidism, drugs such as antidepressants,antipsychotic, opioids, beta blockers, substances such as smoking and alcohol can affect libido.
Erectile dysfunction refers to the inability to attain and maintain a sufficiently rigid penis to permit penetrative sexual intercourse. It is very common and is estimated to affect 50% of all men between the ages of 40-70 yrs sometime during their lifetime. Common causes for ED are Vascular (arterial and venous), neurogenic, hormonal and psychogenic. Erections are Neuro vascular events provoked by thoughts, visual images or dreams.
Erections start when the mind is stimulated by erotic thoughts, visual stimuli or sounds. These electric discharges from the brain stimulate the erection centre in the lower spinal cord (segments T11-L2). Impulses generating from this area, stimulate vasodilation of the blood vessels flowing into the penile muscles. Rapid filling of the penis leads to compression of the penile veins until it leads to the attainment of an erection. When nitric oxide (vasodilatory mediator) is metabolised and also in stimulation of the Noradrenaline system, vasoconstriction occurs and the blood flow into the penis is reduced with subsequent drainage of blood out of the penis and loss of erection (detumescence). Therefore attaining an erection requires appropriate Mental and psychological function, intact neurological pathways, open blood vessels and hormonal activities. Erections can also happen to penile stimulation and spontaneously during sleep (normally 3-4times per night)
Ejaculatory disorders could be premature ejaculation, retrograde ejaculation, delayed ejaculation, anejaculation and anorgasmia. Premature ejaculation refers to when the man ejaculates within a minute of vaginal penetration or sooner than desired. It can occur in upto 30% of men. Retrograde ejaculation refers to backwards discharge of semen during intercourse into the bladder which then comes out during urination. This is one of the causes for infertility and may not require treatment unless fertility is desired. Ejaculation occurring after a reasonable period of sexual activity is called delayed ejaculation. Anejaculation is when there is no ejaculation after sexual stimulation and may be associated with anorgasmia.
What is required to find the cause for male sexual dysfunction?
1. A thorough medical history including a history of diabetes, hypertension, prostate disease, obesity, dyslipidaemia, depression, chronic kidney disease, sleep apnoea, substance abuse and medications (including off label medications) used. A detailed sexual history of the patient, including that of sexual preference, frequency of dysfunction and the circumstances associated with dysfunction needs to be elicited. History of injury to hip or genitals or pelvic surgery may be causative. A history of spontaneous erections occurring at night would make a vascular or neurological disease unlikely and a psychological cause more likely.
2. A thorough medical examination including examination of the genitals and a rectal examination to examine the prostate gland would be needed.
3. A thorough psychological assessment by an experienced counsellor.
4. To do appropriate tests such as general screening tests (CBC, ESR, RFT-E, LFT, Lipid profile, Hba1c, urine complete, stools complete and an ECG. More specific tests might include Thyroid function tests, Testosterone and LH assays, Penile Doppler and Ultrasound whole abdomen and Rectal ultrasound in select cases.
There are 5 broad categories that cause male sexual dysfunction. They include 1.Systemic diseases such as Diabetes, hypertension, heart disease, chronic kidney disease, 2.Psychological causes, 3.medicines (25% of all causes) 4.endocrine disease such as thyroid dysfunction and androgen deficiencies and 5.Neurological causes such as spinal cord diseases, multiple sclerosis and dementia.
Commonly prescribed medicines that can cause sexual dysfunction in men are:
1. Antidepressants – SSRIs
2. Antihypertensives medications: Betablockers, Amlodepine, Chlorthalidone, Enalapril and Doxazosin.
3. Antiandrogens – Androgen deprivation therapy
4. Others- Clonidine, methyldopa, ketoconazole and Spironolactone.
Treatment of Male sexual dysfunction
1. Lifestyle changes – advice patient to stop using recreational drugs including alcohol and cigarettes and help him with Deaddiction. Weight loss and physical activity will also help improve the situation.
2. Professional counselling – counselling patient with partner by a sex therapist may be helpful.
3. To stop medicines that can cause sexual dysfunction.
4. To correct androgen deficiencies and other endocrine disorders ( Thyroid, Prolactin and Estradiol). To stop antiandrogens including Finasteride and Dutasteride if possible.
5. To provide a prescription for a phosphodiesterase 5 inhibitor – Sildenafil, Tadalafil etc.
6. To consider surgery – penile prosthesis
7. Other therapies – use of a vaccine device, intraurethral alprostadil suppository etc. Premature ejaculation can be treated with counselling and use of Lignocaine/Prilocainegel on penis before intercourse.
Patient stories: One gentleman who was 70 yrs old and was on treatment for benign prostatic hypertrophy on Urimax F (Tamsulosin and Finasteride) came to me with a history of erectile dysfunction. I suggested that he change his Tamsulosin to Alfuzocin, stopped the Finasteride and also gave him a prescription for Tadalafil.
Patient 2 was a 50 year old who was on SSRI antidepressant and who reported loss of libido. I asked him to change his Escitolopram to Mirtazapine with good effect.
Patient 3 was a retired banker who had had presented with dullness, slurred speech and memory deficits. Investigations had shown low sodium, hypopituitarism, hypogonadism and atypical tuberculosis.1 yr after recovery he was started on Testosterone injections for lack of libido and ED and reported good improvement in his complaints.
Male sexual dysfunction has many effective therapies but often needs a multidisciplinary approach to providing the best care.